Provider Demographics
NPI:1730269481
Name:HEIST, KENNETH C (DO)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:C
Last Name:HEIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3505
Mailing Address - Country:US
Mailing Address - Phone:215-271-6900
Mailing Address - Fax:215-271-8740
Practice Address - Street 1:2301 S 13TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3505
Practice Address - Country:US
Practice Address - Phone:215-271-6900
Practice Address - Fax:215-271-8740
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006682L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001416642Medicaid
PAHE115020Medicare ID - Type Unspecified
PA0001416642Medicaid